Alcoholics Anonymous: Who Benefits?

Alcoholics Anonymous (AA) is the most popular self-help organization for individuals with alcohol-related problems. This includes both alcohol-dependent and, to a lesser extent, alcohol-abusing drinkers. For many people, self-help through AA is the only alcoholism treatment they receive. Other members join the fellowship before entering professional treatment or are introduced to AA as a component of their professional treatment. Attendance at AA also commonly is recommended as aftercare following professional treatment. Yet experience shows that not all clients benefit from AA to the same extent. Therefore, two questions arise: Who does well in AA, and why do these people succeed? These questions do not have simple answers, however, because outcome (i.e., reduction of drinking or improvement of psychological and social characteristics) associated with AA, as with any kind of alcoholism treatment, is influenced by many characteristics of the clients and the AA groups. For example, the success of AA participation depends not only on an individual's initial decision to attend AA but also on the degree of his or her involvement in AA (e.g., frequency of attendance at meetings, "sharing" at meetings, or serving as or having an AA sponsor). Even similar levels of AA involvement may result in different outcomes for different people, depending on the individual's characteristics and experiences with professional treatment. Despite four decades of AA research, no clear picture has emerged as to which patient characteristics can predict a positive outcome with AA and, therefore, can be used as criteria for matching patients to AA. This is due in part to the limitations and variability of methodological approaches used in the studies. Most investigators recruit their samples from patients in inpatient or outpatient treatment settings. Some studies retrospectively analyze patients with previous AA experience to identify personal characteristics that predicted AA involvement. In other studies, patients are monitored after professional treatment to determine which characteristics may motivate them to join AA and how AA affiliation influences outcome. In both approaches, the kind and impact of the professional treatment often is ignored. Other confounding factors in research about AA include an incomplete understanding of processes within AA and differences among various AA groups. To date, only three randomized clinical trials have examined the efficacy of AA participation, either with or without additional simultaneous treatment approaches (Ditman et al. 1967; Brandsma et al. 1980; Walsh et al. 1991). The vast majority of AA studies, however, have focused on two narrower questions: Which factors predict whether a person will join AA? And how does involvement in AA predict outcome? In an attempt to answer these two questions, Emrick and colleagues (1993) reviewed 107 previously published AA studies. Although their analysis provided estimates of the magnitude of the relationships determining AA affiliation and drinking outcome, it also acknowledged that many relationships may differ when study findings are grouped by client characteristics. Tonigan and colleagues (1994) extended the initial analyses by taking into account factors such as sample gender and origin (i.e., inpatient versus outpatient). This article integrates the findings of these two reviews and concludes with recommendations for future research of AA. WHO JOINS AA? To determine which drinkers were most likely to join AA, Emrick and colleagues (1993) reviewed 33 studies(1) that addressed this question, analyzing 31 demographic and drinking-related client characteristics. The characteristic most strongly correlated with joining AA was the drinkers' previous use of external support mechanisms to stop drinking. The drinkers' demographic characteristics, such as gender, age, and education, were not related to whether or not they joined AA. Factors related to alcohol consumption, such as quantity consumed daily, obsessive preoccupation with alcohol, severity of physical dependence, and loss of control while drinking, however, had some correlational value. …

Alcoholics Anonymous (AA) is the most popular selfhelp organization for individu als with alcoholrelated problems. This includes both alcoholdependent and, to a lesser extent, alcoholabusing drinkers. For many people, selfhelp through AA is the only alcoholism treatment they receive. Other members join the fellowship before entering professional treatment or are introduced to AA as a component of their professional treatment. Attendance at AA also commonly is recommended as after care following professional treatment. Yet experience shows that not all clients bene fit from AA to the same extent. Therefore, two questions arise: Who does well in AA, and why do these people succeed?
These questions do not have simple answers, however, because outcome (i.e., reduction of drinking or improvement of psychological and social characteristics) associated with AA, as with any kind of alcoholism treatment, is influenced by many characteristics of the clients and the AA groups. For example, the success of AA participation depends not only on an individual's initial decision to attend AA but also on the degree of his or her involvement in AA (e.g., frequency of attendance at meetings, "sharing" at meetings, or serving as or having an AA sponsor). Even similar levels of AA involvement may result in different out comes for different people, depending on J. SCOTT TONIGAN, PH.D., is  Despite four decades of AA research, no clear picture has emerged as to which patient characteristics can predict a posi tive outcome with AA and, therefore, can be used as criteria for matching patients to AA. This is due in part to the limitations and variability of methodological approach es used in the studies. Most investigators recruit their samples from patients in inpatient or outpatient treatment settings. Some studies retrospectively analyze patients with previous AA experience to identify personal characteristics that predicted AA involvement. In other stud ies, patients are monitored after profes sional treatment to determine which characteristics may motivate them to join AA and how AA affiliation influences outcome. In both approaches, the kind and impact of the professional treatment often is ignored. Other confounding factors in research about AA include an incomplete understanding of processes within AA and differences among various AA groups.
To date, only three randomized clinical trials have examined the efficacy of AA participation, either with or without addi tional simultaneous treatment approaches (Ditman et al. 1967;Brandsma et al. 1980;Walsh et al. 1991). The vast majority of AA studies, however, have focused on two narrower questions: Which factors predict whether a person will join AA? And how does involvement in AA predict outcome? In an attempt to answer these two ques tions, Emrick and colleagues (1993) reviewed 107 previously published AA studies. Although their analysis provided estimates of the magnitude of the relation ships determining AA affiliation and drinking outcome, it also acknowledged that many relationships may differ when study findings are grouped by client char acteristics. Tonigan and colleagues (1994) extended the initial analyses by taking into account factors such as sample gender and origin (i.e., inpatient versus outpatient). This article integrates the findings of these two reviews and concludes with recom mendations for future research of AA.

WHO JOINS AA?
To determine which drinkers were most likely to join AA, Emrick and colleagues (1993) reviewed 33 studies 1 that addressed this question, analyzing 31 demographic and drinkingrelated client characteristics.
The characteristic most strongly correlated with joining AA was the drinkers' previ ous use of external support mechanisms to stop drinking. The drinkers' demographic characteristics, such as gender, age, and education, were not related to whether or not they joined AA. Factors related to alcohol consumption, such as quantity consumed daily, obsessive preoccupation with alcohol, severity of physical depen dence, and loss of control while drinking, however, had some correlational value. For example, drinkers who had higher levels of alcohol consumption had a greater likelihood of attending AA.
Tonigan and colleagues (1994) ana lyzed whether sample origin (i.e., sample recruitment from outpatient or inpatient settings) affected the correlation between consumptionrelated factors and AA affiliation. The study found that although the overall rate of AA affiliation was comparable for outpatient and inpatient samples, affiliation was modestly corre lated to consumptionrelated factors only in outpatient samples-no such correla tion existed in inpatient samples. One explanation for this difference could be that, in general, there was much greater variation in these factors (e.g., alcohol consumption levels of the patients) among inpatient samples than among outpatient samples. Such variation could attenuate the relationship between consumption related factors and AA affiliation.

DOES AA INVOLVEMENT REDUCE DRINKING?
Without taking into consideration patients' professional treatment experiences, Emrick and colleagues (1993) reviewed 16 studies 1 to determine whether the extent of AA in volvement predicted treatment outcome. Most of the studies found that greater AA involvement could modestly predict re duced alcohol consumption.
When Tonigan and colleagues (1994) examined the influence of gender on this correlation, they found that the relationship between AA involvement and abstinence was stronger in studies that analyzed only men than in studies that included men and women. This finding indicates that men and women may respond differently to AA and that AA involvement may be less beneficial to women. One potential explanation is that women may require different treatment settings than men for optimal treatment outcome (Beckman 1994). Some studies indicate that women may prefer more oneonone treatment (Jarvis 1992) and, consequently, may benefit less from the grouporiented AA setting. Alternatively, AA involvement may be less beneficial for women be cause cooccurring disorders that are more prevalent among women, such as depression, often are not addressed ex plicitly in AA programs. This theory is supported by studies 1 that analyzed alco hol consumption and AA attendance in clients who already had completed profes sional treatment, during which any co existing psychiatric disorders presumably would have been addressed. Therefore, the women would not have to rely on AA to serve as their sole source of treatment for both alcoholrelated and psychiatric problems. These studies found only small differences between men's and women's outcome as a result of AA involvement.
Other studies 1 analyzed the relation ship between AA involvement and im proved psychosocial functioning. These studies used measures such as marital satisfaction; employment status; or scores on the Minnesota Multiphasic Personality Inventory, a questionnaire used to meas ure psychological functioning. Tonigan and colleagues (1994) found modest positive relationships between AA atten dance and improvement of these meas ures. However, psychosocial improve ment was not the same for all client popu lations. For example, among clients who received no professional treatment, men appeared to improve more than women. Among clients receiving professional treatment in addition to participating in AA, those in outpatient programs reported greater psychological improvement as a result of AA attendance than did those in inpatient programs.

RECOMMENDATIONS FOR FUTURE AA RESEARCH
Although the analysis of AA studies suggests some patient characteristics that influence affiliation with AA or drinking and psychological outcome, the existing research still has severe methodological flaws, as was mentioned earlier. For example, the patient samples used in many studies do not represent adequately the general AA member population, and demographic patient characteristics often are not described thoroughly. Also, the

RESEARCH UPDATE
instruments used to measure drinking, AA affiliation and involvement, and outcome often rely on patients' selfreporting, a method that inherently involves variabili ty and may lack reliability. A plethora of innovative research approaches and ques tions have been suggested to strengthen AA research (McCrady and Miller 1993), such as those discussed below.
First, patient samples in AA studies should represent AA member composition more accurately. In particular, the under representation of adolescents and women in AA research must be corrected. To be more informative, studies also should report routinely patient characteristics, such as age, gender, marital and employment status, and severity of drinking problems.
Second, followup protocols for AA studies should be extended. With some exceptions (e.g., Sheeren 1988; Vaillant 1983), AA studies have not conducted longterm followup. In the studies re viewed by Emrick and colleagues (1993), the average assessment time after affilia tion with AA was 18 weeks. Given the lifelong commitment expected of AA members, it is doubtful whether such a short period is sufficient to detect mean ingful changes.
Third, factors promoting AA involve ment must be better identified and under stood. Evidence suggests that the extent of involvement in AA, rather than the frequency of attendance, predicts how individuals fare in AA (e.g., Snow et al. 1994). However, there still is no consen sus on how to assess involvement and even less consensus on the factors that influence whether, and how much, a per son becomes involved. Health care profes sionals and researchers, because of their clinical experience and contact with AA members, could be valuable resources for developing reliable instruments to meas ure involvement.
Fourth, future research should pay more attention to patienttreatment match ing approaches and examine how different types of professional alcoholism treatment and different patient characteristics relate to AA involvement and drinking behavior. For example, existing evidence suggests that women do better in AA after having had prior professional treatment, rather than without having had such treatment, and that AA members who receive outpa tient treatment fare better than those who receive inpatient treatment.
A patienttreatment matching ap proach also could include comparisons of the philosophies behind different professional treatment approaches and AA. Philosophical similarity between a specific program and AA may increase a patient's acceptance of AA principles, thus improving the patient's involvement and, consequently, outcome with AA. Conversely, philosophical differences could negatively affect a patient's in volvement and outcome with AA.
When matching clients to AA, differ ences between individual AA groups also may need to be considered. AA is not a single entity. A study by Montgomery and colleagues (1993) found that AA groups vary in their social structure and their characteristics, such as perceived cohesiveness, aggressiveness, and ex pressiveness. Some clients may be more attracted and responsive to specific group characteristics than others. Consequently, it may not be realistic to expect to find general predictors of affiliation and out come with AA. ■

Liver Transplantation and Alcoholism Rehabilitation
THOMAS BERESFORD, M.D.
In the excitement of finding a remark ably high rate of firstyear abstinence among his alcoholic liver transplant patients (Starzl et al. 1988), Dr. Thomas Starzl, the pioneer of transplant surgery in this country, commented to the press that liver transplantation might be the ultimate cure for alcoholism. 1 His study of transplanted alcoholic patients was published with little comment on meth ods of patient selection or of posttrans plant care. Five years later Starzl and colleagues presented data that argued the opposite case-that those with alcoholic hepatitis and cirrhosis show remarkably high rates of relapse to uncontrolled drinking despite having undergone liver transplantation (see Bonet et al. 1993). How can one find a rational approach between these two extremes? The best answer is a complex one, requiring a careful understanding of the methods of preoperative patient selection and of postoperative care. This article offers a brief overview of the topic; for more detail, see Lucey et al. 1994. Table 1 lists the data from four liver transplant programs. These programs have reported 1year abstinence rates among liver transplant recipients who also suf fered from preexisting alcohol addiction. All programs reported firstyear absti nence rates that approximated 90 percent, a remarkably high frequency when com pared with the 30 to 50percent range reported in alcoholism treatment studies that did not involve a procedure as drastic as liver transplantation (Moos 1990;Vaillant 1983). On the surface, it is easy to conclude that a chronic lifethreatening illness, followed by the extreme stress of a lengthy operation and its ensuing recov ery, might deter a patient from future drink ing. There is the added implication that the patient will not receive another transplant if drinking begins again and results in a second liver failure.
A closer look at the programs reveals several common threads. Each program carefully selects and then follows those alcoholdependent patients for whom the program will agree to provide a liver trans plantation. Selection is based in part on the perceived risk that a particular patient will return to uncontrolled alcohol use. The University of Michigan's liver transplant program has led in the development of selection procedures for alcoholic trans plant candidates (Beresford et al. 1990), and each of the other programs incorporates some aspects of these procedures in their own formulations. However, the questions arise: Are there empirical guidelines for predicting longterm remission from alco hol dependence? In particular, does the

PREDICTING ABSTINENCE
Research has shown the following charac teristics among patients who are likely to maintain longterm abstinence: (1) self recognition of alcohol dependence and acceptance of it as a condition to be dealt with, (2) a socially stable living environ ment, (3) freedom from severe psychiatric disorders, and (4) available resources that facilitate continued abstinence (Beresford 1990;Lucey et al. 1994).
Vaillant's work (1983) is especially pertinent. In an 8year prospective 2 study, he noted that alcoholics who had been abstinent for 3 years or longer had at least two of four clinical indicators. First, they structured their time with substitute activ ities that limited the potential time they could spend drinking. Second, they had developed a relationship with a person committed to their wellbeing who put clear limits on his or her toleration of their drinking. Third, they found a sense of hope or of improved selfesteem in some aspect of their lives that counteract ed the often intense guilt they felt as a result of their pathological alcohol use. Fourth, they suffered some noxious con sequence of drinking, such as severe abdominal pain from pancreatic inflam mation or an ethanoldisulfiram reaction 3 (see the article by Anton, pp. 265-271).
As most liver transplant programs now realize, alcoholic candidates who recog nize their alcohol dependence as a serious and continuing health risk, who have a socially stable environment, and who pos sess most or all of the factors described by Vaillant are unlikely to relapse to alcoholic drinking during the first 12 months after a liver transplant. However, it is not certain whether these factors are the actual cause of relapse prevention in these patients.
For most liver transplant recipients, all the predictive factors that Vaillant eluci dated occur in the natural course of post operative care during the first year (Beres ford et al. 1992). For example, the thought of death as a direct and negatively per